Lincoln Highway Association: Application Form

Date: ____________________ Annual membership is from date of enrollment.

( ) New Membership ( ) Renewal

Membership Categories:

( ) Student:* $25
( ) Individual: $45
( ) Family: $60

( ) Libraries, museums & historical societies: $45
( ) Local, state, and county governments: $45
( ) Supporting: $75

( ) Patron: $150
( ) Business: $75

( ) Corporate: $150
( ) Life: $1000 and up

* Students: include copy of front and back of student ID card

State Affiliation

Members who live in Lincoln Highway states are automatically members of that state's chapter. Dues for additional chapter memberships are $9.00 per year per state. Check the appropriate box below.

[ ] NY
[ ] IN
[ ] CO

[ ] NJ
[ ] IL
[ ] UT

[ ] PA
[ ] IA
[ ] NV

[ ] WV
[ ] NE
[ ] CA

[ ] OH
[ ] WY

If you would like to serve on a committee, which one?

[ ] Awards
[ ] Bylaws
[ ] Conference

[ ] Fund Raising
[ ] Government Relations
[ ] Highway Preservation & Interpretive Sites

[ ] Historic & Contemporary Markers
[ ] Historic Resources
[ ] Marketing

[ ] Nominating
[ ] Public Relations
[ ] Headquarters
[ ] LHA 2013 Centennial

Please Print

Name	____________________
Address	____________________
City	_________	State	__	Zip	_____

Home phone	(__) ___________
Work phone	(__) ___________
Fax	(__) ___________
E-mail address	______________

What do/did you do for a living? _____________________________________

The Lincoln Highway Association is exclusively charitable and educational, within the interpretation of Section 501(c)(3) of the Internal Revenue Code.

Payment Method:

( ) Check (payable to Lincoln Highway Association)

Credit card: ( ) Visa ( ) MasterCard ( ) Discover

Name on card (if other than above):	________________
Address on card (if other than above):	________________
Card number (16 digits):	________________
Expiration Date:	___ / ___
Signature:	________________